PKG00264372-instructions.pdf

Administration for Community Living

Administration on Aging

2021 Integrated Networks to Deliver and Sustain Evidence-Based Chronic Disease Self- Management Education Programs

HHS-2021-ACL-AOA-CSSG-0014

02/02/2021

Table of Contents Executive Summary

Additional Overview Content/Executive Summary

I. Funding Opportunity Description

II. Award Information

III. Eligibility Information

1. Eligible Applicants

2. Cost Sharing or Matching

3. Responsiveness and Screening Criteria

IV. Application and Submission Information

1. Address to Request Application Package

2. Content and Form of Application Submission

Letter of Intent

Project Narrative

Project Abstract

Project Relevance and Current Need

Approach

Outcomes and Evaluation

Sustainability

Organizational Capacity

Budget Narrative/Justification

3. Submission Dates and Times

4. Intergovernmental Review

5. Funding Restrictions

6. Other Submission Requirements

V. Application Review Information

1. Criteria

2. Review and Selection Process

3. Anticipated Announcement Award Date

VI. Award Administration Information

1. Award Notices

2. Administrative and National Policy Requirements

3. Reporting

4. FFATA and FSRS Reporting

VII. Agency Contacts

VIII. Other Information

The Paperwork Reduction Act of 1995 (P.L. 104-13)

Appendix

Instructions for Completing Required Forms

Budget Narrative/Justification- Sample Format

Instructions for Completing the Project Summary/ Abstract

ACL Center:

Administration on Aging Funding Opportunity Title:

2021 Integrated Networks to Deliver and Sustain Evidence-Based Chronic Disease Self- Management Education Programs Funding Opportunity Number:

HHS-2021-ACL-AOA-CSSG-0014

Primary CFDA Number:

93.734 Due Date for Letter of Intent:

12/18/2020 Due Date for Applications:

02/02/2021 Date for Informational Conference Call:

12/11/2020 Applications that fail to meet the application due date will not be reviewed and will receive no further consideration. You are strongly encouraged to submit your application a minimum of 3-5 days prior to the application closing date. Do not wait until the last day in the event you encounter technical difficulties, either on your end or, with https://www.grants.gov. Grants.gov can take up to 48 hours to notify you of a successful submission.

Executive Summary Additional Overview Content/Executive Summary Through this funding opportunity, the Administration on Aging (AoA), part of the Administration for Community Living (ACL), plans to award approximately 3 cooperative agreements to domestic public or private non-profit entities.

The intent of these awards is to strengthen integrated networks that address the behavioral and social determinants of health of older adults and adults with disabilities, and increase the number of these individuals who participate in evidence-based chronic disease self-management education and self-management support programs.

Applicants may request a total budget from $1,100,000 to a maximum of $1,400,000 for the three-year project period. All awards will be subject to the availability of federal funds.

https://www.grants.gov/

The awards will be made in the form of cooperative agreements because AoA will be substantially involved. These cooperative agreements have an anticipated start date of May 1, 2021.

An informational conference call will be held on December 11, 2020 from 12:00 PM EST.

The dial-in information is below:

Toll Free Number: 888-947-8932; Passcode: 7495880

A recording will be available approximately one hour after the call concludes at the following number: 888-568-0182

I. Funding Opportunity Description Background The Administration for Community Living’s (ACL’s) mission is to maximize the independence, well-being, and health of older adults, people with disabilities, and their families and caregivers.

ACL’s programs provide individualized, person-centered home and community-based services and supports, as well as invest in research and best practices, to make community living a reality for millions of people. [1] Delivered through the national aging and disability services network and their partners, ACL supports effective and efficient programs and services that address the social and behavioral determinants of health for millions of older adults and persons with disabilities each year. [2][3] The aging and disability networks reach into every community across the nation and function as the trusted “eyes and ears” of a person’s home and community environments. When essential social and behavioral determinants of health, i.e., adequate nutrition, safe housing, and access to health care services go unmet, we know that this puts older adults and adults with disabilities at greater risk for chronic disease and other threats to their health and independence. [4]

Across the nation, many aging and disability networks are engaged in community integrated health networks in an effort to provide older adults, individuals with disabilities, and other high cost, high need populations with streamlined access to services to help them remain healthy, in ways that respect individual preferences, goals, and interests. These networks are comprised of a group of visible and trusted aging and disability organizations, led by a Network Lead Entity (NLE), who have formal partnerships with health care and other relevant sectors to address health and social needs in a coordinated way. NLEs function as a one-stop-shop for contracting with health care entities, and often deploy a multi-payer strategy to ensure individuals have access to needed programs and services; beyond contractual arrangements with health care entities, other sources of financing that networks may draw upon are federal grants (e.g. Older Americans Act and discretionary) or other publicly-funded resources at the state or local levels, philanthropic support, private pay arrangements, and civic/community investment (e.g. local businesses, United Way, etc.). An important part of any robust community integrated health network is the inclusion of evidence-based health promotion and disease prevention programs. Indeed, results from the Aging and Disability Business Institute’s 2020 Request for Information indicate that evidence-based programs are the second most common service provided through contracts (behind case management/care or service coordination). A March 2020 Community Integrated Health Network Report provides more information about the intent, https://acl.gov/sites/default/files/common/BA_roundtable_workgroup_paper_2020-03-01-v3.pdf https://acl.gov/sites/default/files/common/BA_roundtable_workgroup_paper_2020-03-01-v3.pdf https://www.aginganddisabilitybusinessinstitute.org/wp-content/uploads/2020/10/RFI-III-2020-webinar-presentation-2020.10.21-Final.pdf.

https://acl.gov/sites/default/files/common/BA_roundtable_workgroup_paper_2020-03-01-v3.pdf guiding principles, and function/structure of these networks, and an example of one network.

Over nearly two decades. ACL’s Administration on Aging has worked to increase access to, and the sustainability of, evidence-based programs that help older adults make positive changes to maintain and/or improve their health. This portfolio of programs includes interventions focused on chronic disease self-management, behavioral health, medication management, physical activity, falls prevention, and other important areas. These proven programs, alongside the other services and supports the aging and disability networks provide, are essential in helping older adults and older adults with disabilities live healthy and independent lives.

In the United States, approximately three out of four older adults have multiple (two or more) chronic conditions, such as diabetes, arthritis, heart disease, chronic pain, and depression. [5] This burden places older adults at greater risk for premature death, poor oral health, poor functional status, unnecessary hospitalizations, adverse drug events, and nursing home placement. [6],[7] Chronic conditions also impact health care costs: 95% of health care costs for older Americans can be attributed to chronic diseases.

Evidence-based chronic disease self-management education (CDSME) programs can help mitigate chronic disease burden by empowering participants to better manage their conditions.

The acronym, CDSME, is being used in this announcement as an umbrella term for community-based education programs specifically designed to enhance patient self- management of chronic illnesses, focus on building multiple health behaviors and generalizable skills such as goal setting, decision making, problem-solving, and self-monitoring, and are proven to maintain or improve health outcomes of older adults with chronic conditions. [5]

AoA has supported CDSME and other evidence-based health promotion programs for many years through grants, as well as collaborations on various federal initiatives. For example, Prevention and Public Health Fund initiatives in 2020 supported 11 CDSME grantees.

Additionally, Older Americans Act Title III-D funding supports a broader portfolio of evidence-based disease prevention and health promotion activities. For more information about ACL’s CDSME Program, including profiles of current grantees, please visit:

https://www.acl.gov/programs/health-wellness/chronic-disease-self-management-education-programs.

Purpose This funding opportunity has two goals:

Goal 1: Strengthen state or regional Community Integrated Health Networks that address the social and behavioral determinants of health of older adults and adults with disabilities.

These Networks should have the capacity to deliver, strategically incorporate, and embed evidence-based chronic disease self-management education (CDSME) and self-management support programs within their broader context that includes other programs/services that address social determinants of health (e.g. nutrition, transportation, care coordination, etc.).

These networks should have:

https://www.acl.gov/programs/health-wellness/chronic-disease-self-management-education-programs https://www.acl.gov/programs/health-wellness/chronic-disease-self-management-education-programs

1. A Network Lead Entity that is working in partnership with a variety of community-based organizations across a geography to provide a centralized, coordinated model for service provision, administrative functions, and quality improvement. The collective network should have the ability to provide a range of services, including CDSME/self-management support programs. Beyond the partnering community-based organizations, the network should also include state level partnerships (i.e., State Units on Aging, Public Health, etc.), local level partnerships (i.e., AAAs, Centers for Independent Living, etc.), and strategic engagement of health care entities.

2. Sustainability strategies including, but not limited to, a business plan with clear strategies, contracts, and/or other means to secure and expand sustainable financing (including non-federal funding), infrastructure to receive reimbursement for services, and information technology solution(s) that allows for referral management (including closed loop referrals), participant tracking across interventions, and outcome measurement.

3. Strategic partnerships with other entities involved in evidence-based CDSME/self-management support program work.

4. Multi-site delivery partners who have the infrastructure and capacity to increase access to evidence-based CDSME/self-management support programs with a defined geographic or population base, and a commitment to embedding these programs into their routine operations and budget.

5. Coordinated public awareness, education, marketing, and recruitment processes.

6. Ongoing quality assurance efforts including fidelity monitoring and continuous quality improvement.

Goal 2: Significantly increase the number of older adults and adults with disabilities who participate in evidence-based CDSME and self-management support programs to empower them to better manage their chronic conditions.

Please refer to Appendix A (Glossary of Terms) for definitions of CDSME and self-management support programs.

Applicants for this funding opportunity must propose to deliver two or more CDSME/self-management support programs on the pre-approved lists in Appendix B and C of this funding announcement. At least one of the programs proposed must be a CDSME program from Appendix B.

All applicants must propose to implement at least one program that can be delivered in a remote format, i.e., by video conference, phone, mailed toolkit + phone, or some other format that does not have an in-person component.. The National Council on Aging (NCOA) maintains a website that tracks remote program guidance by program (https://www.ncoa.org/news/ncoa-news/center-for-healthy-aging-news/track-health-promotion-program-guidance-during-covid-19/). However, all applicants should contact the program administrator(s) for any program(s) they are interested in delivering remotely to confirm that: 1) the programs are allowed for remote delivery; and 2) that training is readily available for applicants who need it. Note that the NCOA website https://www.ncoa.org/news/ncoa-news/center-for-healthy-aging-news/track-health-promotion-program-guidance-during-covid-19/ https://www.ncoa.org/news/ncoa-news/center-for-healthy-aging-news/track-health-promotion-program-guidance-during-covid-19/ includes programs on the pre-approved list in Appendix B and C, as well as other programs not on the list. For this funding opportunity, applicants may ONLY propose programs on the pre-approved lists in Appendix B and C.

All applicants who do not have adequate existing capacity for any in-person and/or remote program(s) they are proposing must include a letter from the program administrator in their application indicating that they will be able to get training in the program no later than three months after the start date of the grant (if selected for funding).

References

[1] U.S. Department of Health and Human Services, Administration for Community Living.

(2019). FY2016 Report to Congress: Older Americans Act.

[2] World Health Organization (2019). Social Determinants of Health, Accessed October 2, 2019 from https://www.who.int/social_determinants/en/.

[3] ACL Office of Performance and Evaluation (2019). Program Evaluations and Reports.

Accessed October 2, 2019 from https://acl.gov/programs/program-evaluations-and-reports.

[4] U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion (2019). Healthy People 2020: Social Determinants, Accessed October 2, 2019 from https://www.healthypeople.gov/2020/about/foundation-health-measures/Determinants-of- ; ;Health#individual%20behavior.

[5] Gerteis J, Izrael D, Deitz D, LeRoy L, Ricciardi R, Miller T, Basu J. Multiple Chronic Conditions Chartbook. AHRQ Publications No, Q14-0038. Rockville, MD: Agency for Healthcare Research and Quality. April 2014.

[6] Parekh, A.K., et al. 2011. Managing Multiple Chronic Conditions: A Strategic Framework for Improving Health Outcomes and Quality of Life. Public Health Rep. 126(4):460–71.

[7] Kramarow E. et al. 2007. Trends in the Health of Older Americans,1970–2005. Health Affairs (Millwood). Sep-Oct;26(5):1417 25

Statutory Authority The statutory authority for grants under this Funding Opportunity Announcement is contained in the Continuing Appropriations Act, 2020, Pub.L.116-59; Older Americans Act; and the Patient Protection and Affordable Care Act, 42 U.S.C. § 300u-11 (Prevention and Public Health Fund).

II. Award Information Funding Instrument Type:

CA (Cooperative Agreement) Estimated Total Funding:

$ 4,130,440 Expected Number of Awards:

Award Ceiling:

$ 1,400,000 Per Project Period

Award Floor:

$ 1,100,000 https://www.who.int/social_determinants/en/ https://acl.gov/programs/program-evaluations-and-reports https://www.healthypeople.gov/2020/about/foundation-health-measures/Determinants-of-Health#individual%20behavior https://www.healthypeople.gov/2020/about/foundation-health-measures/Determinants-of-Health#individual%20behavior

Per Project Period

Length of Project Period:

Other Additional Information on Project Periods and Explanation of 'Other' 36 month project and budget period (fully funded)

Current or previous ACL Chronic Disease Self-Management Education grantees are not excluded from this funding opportunity, but must provide a strong rationale for the need for additional funding. This must include significant enhancement of the network developed with prior funding, not be a continuation of current efforts/activities supported by previously awarded ACL CDSME grants (particularly because sustainability without additional federal funding has been a goal of all previous ACL CDSME funding opportunities). Applicants must propose an innovative approach that addresses the goals of this funding opportunity that features new partnerships and/or programs. Repeat awardees will be expected to meet the discrete participant and/or completer and sustainability goals that they included in each of their awards.

Cooperative Agreement Terms This is a new Cooperative Agreement with the following terms. As provided by the terms of the Federal Grant and Cooperative Agreement Act of 1977 (P.L. 95-224), this Cooperative Agreement provides for the substantial involvement and collaboration of AoA in activities that the recipient organization will carry out in accordance with the provisions of the approved grant award.

The grantee agrees to execute the responsibilities outlined below:

1. Fulfill all of the requirements of the grant initiative as outlined in this program announcement, as well as carry out project activities as reviewed, approved, and awarded.

2. Engage 25% of your target completers (for CDSME programs) and participants (for self-management support programs) by the end of Year 1, 50% by the end of Year 2, and 100% by the end of Year 3.

3. Commit to sending two project staff to a yearly CDSME-relevant professional development conference mutually agreed upon with the AoA project officer as an appropriate grantee activity. Attendance is expected annually for the duration of your grant activities (including any no-cost extension period, if applicable). Although it remains yet to be seen if future conferences will be in-person or video conference (not requiring travel), all applicants must include funds in your budgets for each budget year for two people to attend a conference in the Washington, D.C. area. Awardees will be able to apply any unused travel funds to other grant activities.

4. Meet all training, licensing, fees, or other requirements associated with the selected CDSME/self-management support programs to ensure compliance with all the requirements stipulated by the authorizing entity.

5. Communicate with the AoA project officer monthly, or at such other times as are agreed upon, to improve the effectiveness of the activities carried out under this Agreement.

6. Collect required program data for all program participants by way of ACL’s specific data collection forms (see Appendix D). Within 30 days of participants’ completion of the program, grantees are responsible for compiling and reporting the data to the CDSME National Database. Data include de-identified participant demographic and health status information, attendance information, and workshop type and location. Grantees should plan to train workshop leaders on data collection practices and use of these forms.

7. Participate in any national evaluations of the program(s) you have proposed for remote delivery.

8. Comply with all other reporting requirements, as outlined in Section VI of this Funding Opportunity and the Notice of Award.

9. Include the following disclaimer on all products produced using this grant funding:

This project was supported in part by grant number 90XX#### from the Administration for Community Living, U.S. Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects with government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy.

The AoA project officer agrees to execute the responsibilities outlined below:

1. Perform the day-to-day Federal responsibilities of managing a cooperative agreement and work with the grantee to ensure that the minimum requirements for the grant are met.

2. Work cooperatively with the grantee to clarify the programmatic and budgetary issues to be addressed by the grantee project, and, as necessary, negotiate with grantee to achieve a mutually agreed upon solution to any needs identified by the grantee or AoA.

3. Assist the grantee project leadership in understanding the strategic goals and objectives, policy perspectives, and priorities of AoA, ACL, and the U.S. Department of Health and Human Services; and about other federally-sponsored projects and activities relevant to activities funded under this announcement.

4. Provide technical advice to the grantee on the provision of technical support and associated tasks related to the fulfillment of the goals and objectives of this grant.

5. Attend and participate in major project events, as appropriate.

6. Communicate with the grantee project director monthly, or at such other times as are agreed upon, to improve the effectiveness of the activities carried out under this Agreement.

Once a cooperative agreement is in place, requests to modify or amend it or the work plan may be made by ACL or the awardee at any time as long as it stays within the original confines of the proposed project description. Major changes may affect the integrity of the competitive review process. Modifications and/or amendments of the Cooperative Agreement or work plan shall be effective upon the execution of an award notice. Unless ACL is authorized under the Terms and Conditions of award, 45 CFR Part 75, or other applicable regulation or statute to make unilateral amendments. When an award is issued the cooperative agreement terms and conditions from the program announcement are incorporated by reference.

III. Eligibility Information

1. Eligible Applicants Domestic public or private non-profit entities including state and local governments, Indian tribal governments and organizations (American Indian/Alaskan Native/Native American), faith-based organizations, community-based organizations, hospitals, and institutions of higher education.

2. Cost Sharing or Matching Cost Sharing / Matching Requirement:

No For awards that require matching or cost sharing by statute, recipients will be held accountable for projected commitments of non-federal resources (at or above the statutory requirement) in their application budgets and budget justifications by budget period, or by project period for fully funded awards. The applicant will be held accountable for all proposed non-federal resources as shown in the Notice of Award (NOA). A recipient's failure to provide the statutorily required matching or cost sharing amount (and any voluntary committed amount in excess) may result in the disallowance of federal funds. Recipients will be required to report these funds in the Federal Financial Reports.

For awards that do not require matching or cost sharing by statute, recipients are not expected to provide cost sharing or matching. However, recipients are allowed to voluntarily propose a commitment of non-federal resources. If an applicant decides to voluntarily contribute non-federal resources towards project costs and the costs are accepted by ACL, the non-federal resources will be included in the approved project budget. The applicant will be held accountable for all proposed non-federal resources as shown in the Notice of Award (NOA). A recipient's failure to meet the voluntary amount of non-federal resources that was accepted by ACL as part of the approved project costs and that was identified in the approved budget in the NOA, may result in the disallowance of federal funds. Recipients will be required to report these funds in the Federal Financial Reports.

3. Responsiveness and Screening Criteria Application Responsiveness Criteria N/A

Application Screening Criteria All applications will be screened to assure a level playing field for all applicants. Applications that fail to meet the three screening criteria described below will not be reviewed and will receive no further consideration.

In order for an application to be reviewed, it must meet the following screening requirements:

1. Applications must be submitted electronically via https://www.grants.gov by 11:59 p.m., Eastern Time, by the due date listed in section IV.3 Submission Dates and Times.

2. The Project Narrative section of the Application must be double-spaced, on 8.5” x 11” plain white paper with 1” margins on both sides, and a standard font size of no less than 11 point, preferably Times New Roman or Arial.

3. The Project Narrative must not exceed 20 pages. Project Narratives that exceed 20 pages will have the additional pages removed and only the first 20 pages of the Project Narrative will be provided to the merit reviewers for funding consideration. NOTE: The Project Work Plan, Letters of Commitment, and Vitae of Key http://www.grants.gov/

Project Personnel are not counted as part of the Project Narrative for purposes of the 20-page limit.

Unsuccessful submissions will require authenticated verification from https://www.grants.gov indicating system problems existed at the time of your submission.

For example, you will be required to provide an https://www.grants.gov submission error notification and/or tracking number in order to substantiate missing the application deadline.

IV. Application and Submission Information

1. Address to Request Application Package Application materials can be obtained from https://www.grants.gov or https://www.acl.gov/grants/applying-grants.

Please note, ACL requires applications for all announcements to be submitted electronically through http://www.grants.gov in Workspace. Grants.gov Workspace is the standard way for organizations and individuals to apply for federal grants in Grants.gov. An overview and training on Grants.gov Workspace can be found here at:

https://www.grants.gov/web/grants/applicants/workspace-overview.html

The Grants.gov registration process can take several days. If your organization is not currently registered, please begin this process immediately. For assistance with https://www.grants.gov, please contact them at support@grants.gov or 800-518-4726 between 7:00 a.m. and 9:00 p.m.

Eastern Time.

At the https://www.grants.gov website, you will find information about submitting an application electronically through the site, including the hours of operation. ACL strongly recommends that you do not wait until the application due date to begin the application process because of the time involved to complete the registration process.

All applicants must have a DUNS number (https://fedgov.dnb.com/webform/) and be registered with the System for Award Management (SAM, www.sam.gov) and maintain an active SAM registration until the application process is complete, and should a grant be made, throughout the life of the award. Effective June 11, 2018, when registering or renewing your registration, you must submit a notarized letter appointing the authorized Entity Administrator. Please be sure to read the FAQs located at www.sam.gov to learn more. Applicants should allot sufficient time prior to the application deadline to finalize a new, or renew an existing registration. This action should allow you time to resolve any issues that may arise. Failure to comply with these requirements may result in your inability to submit your application or receive an award. Maintain documentation (with dates) of your efforts to register or renew at least two weeks before the deadline. See the SAM Quick Guide for Grantees at:

https://www.sam.gov/SAM/pages/public/help/samQUserGuides.jsf.

Note: Once your SAM registration is active, allow 24 to 48 hours for the information to be available in Grants.gov before you can submit an application through Grants.gov. This action should allow you time to resolve any issues that may arise. Failure to comply with these requirements may result in your inability to submit your application or receive an award.

http://www.grants.gov/ http://www.grants.gov/ https://www.grants.gov/ https://www.acl.gov/grants/applying-grants http://www.grants.gov/ https://www.grants.gov/web/grants/applicants/workspace-overview.html https://www.grants.gov/ mailto:support@grants.gov https://www.grants.gov/ https://fedgov.dnb.com/webform/ http://www.sam.gov/ https://www.sam.gov/SAM/pages/public/help/samQUserGuides.jsf

Note: Failure to submit the correct EIN Suffix can lead to delays in identifying your organization and access to funding in the Payment Management System.

Effective October 1, 2010, HHS requires all entities that plan to apply for and ultimately receive federal grant funds from any HHS Operating/Staff Division (OPDIV/STAFFDIV) or receive subawards directly from the recipients of those grant funds to:

1. Register in SAM prior to submitting an application or plan;

2. Maintain an active SAM registration with current information at all times during which it has an active award or an application or plan under consideration by an OPDIV; and

3. Provide its DUNS number in each application or plan to submit to the OPDIV.

Additionally, all first-tier subaward recipients must have a DUNS number at the time the subaward is made.

Since October 1, 2003, The Office of Management and Budget has required applicants to provide a Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) number when applying for federal grants or cooperative agreements. It is entered on the SF-424. It is a unique, nine-digit identification number, which provides unique identifiers of single business entities. The DUNS number is free and easy to obtain.

Organizations can receive a DUNS number at no cost by calling the dedicated toll-free DUNS Number request line at 866-705-5711.

You must submit all documents electronically, including all information included on the SF424 and all necessary assurances and certifications. In accordance with the Federal Government’s efforts to reduce reporting burden for recipients of federal financial assistance, the general certification and representation requirements contained in the Standard Form 424B (SF-424B) – Assurances – Non-Construction Programs, and the Standard Form 424D (SF-424D) – Assurances – Construction Programs, have been standardized federal-wide.

Effective January 1, 2020, the updated common certification and representation requirements will be stored and maintained within SAM. Organizations or individuals applying for federal financial assistance as of January 1, 2020, must validate the federally required common certifications and representations annually through SAM located at SAM.gov.

After you electronically submit your application, you will receive an automatic acknowledgement from https://www.grants.gov that containshttps://www.grants.gov tracking number. The Administration for Community Living will retrieve your application form fromhttps://www.grants.gov.

U.S. Department of Health and Human Services Administration for Community Living

Shannon Skowronski E-mail: shannon.skowronski@acl.hhs.gov https://www.grants.gov/

2. Content and Form of Application Submission Letter of Intent Due Date for Letter Of Intent 12/18/2020

12/18/2020 Applicants are requested, but not required, to submit a letter of intent to apply for this funding opportunity to assist ACL in planning for the application independent review process. The purpose of the letter of intent is to allow our staff to estimate the number of independent reviewers needed and to avoid potential conflicts of interest in the review. Letters of intent should be sent to:

U.S. Department of Health and Human Services

Administration for Community Living

Shannon Skowronski

Administration on Aging

E-mail: shannon.skowronski@acl.hhs.gov

Project Narrative The Project Narrative must be double-spaced, on 8 ½” x 11” paper with 1” margins on both sides, and a standard font size of not less than 11, preferably Times New Roman or Arial. The entirety of the Project Narrative, including tables, graphics, and headings must be double-spaced, and of a standard font size of not less than 11. You can use smaller font sizes to fill in the Standard Forms and Sample Formats outside of the Project Narrative section, such as the Project Work Plan and Budget Narrative/Justification.

Twenty pages is the maximum length allowed. Project Narratives that exceed 20 pages will have the additional pages removed and only the first 20 pages of the Project Narrative will be provided to the merit reviewers for funding consideration. The Project Work Plan, Letters of Commitment, Vitae of Key Project Personnel, and Budget Narrative/Justification are not counted as part of the Project Narrative for purposes of the 20-page limit.

The Project Narrative is the most important part of the application, since it will be used as the primary basis to determine whether your project meets the minimum requirements for grants under the authorizing statutes. The Project Narrative should provide a clear and concise description of your project. ACL recommends that your project narrative include the following components:

1. Project Abstract

2. Project Relevance and Current Need

3. Approach

4. Outcomes and Evaluation

5. Sustainability

6. Organizational Capacity

To assist reviewers in scoring your application, we suggest that applicants organize their proposals using the headings above.

Project Abstract This section should include a brief description of the proposed project, including goal(s), objectives, and outcomes.

In your abstract, clearly specify:

1. The proposed CDSME and/or self-management support programs you plan to implement/disseminate;

2. Your key partners; and

3. Your projected number of program completers (for CDSME programs) and participants

(for self-management support programs).

Project Relevance and Current Need Briefly describe and cite (using reliable population-based, state, and local data sources) the impact of chronic disease in your state/region/tribe and how your proposed project will address this impact.

Briefly describe your community integrated health network’s experience and current capacity to deliver evidence-based CDSME/self-management support programs.

Describe the gap between the current availability of your proposed CDSME/self-management support programs and the ideal situation where these programs are readily available.

Include a Project Map of your state/region/tribe that shows where your proposed programs are already being offered (is applicable), and which areas are being selected for this project. Provide data to support why you are targeting those areas (e.g., the number of older adults, the lack of available programs, etc.). The map should be included as an appendix to your application.

If you are a current or past ACL CDSME grantee, you must describe how your proposed project significantly differs from your current or previously funded work, including:

o what your participant and completer targets were and if you met or are on pace to meet them;

o the extent to which you secured innovative funding arrangements to continue to offer and/or expand the availability of CDSME/self-management support programs beyond the end of the grant period; and o your rationale for the need for additional funding (i.e. not a continuation of current efforts, but rather an innovative approach that features new partnerships and/or programs, substantially increased geographic reach, and increased engagement of older adults and/or adults with disabilities that experience health disparities).

Approach Project Description This section should:

State the project's result-based goals and major objectives.

Describe the extent to which you are currently addressing the social and behavioral determinants of health for older adults and adults with disabilities in your community through supporting the delivery and/or facilitation of streamlined access to services and supports through a community integrated health network.

Describe the unmet social and behavioral determinants of health that put older adults and adults with disabilities in your community at greater risk for chronic disease.

Identify the specific evidence-based CDSME/self-management support programs that you propose to implement and a rationale for selecting the programs. Applicants must propose to implement a minimum of two CDSME/self-management support programs that are on the list of pre-approved programs (in Appendix B and Appendix C). At least one of the proposed programs must be a CDSME program (in Appendix B). Do not propose programs that are not included on the lists in Appendices B and C. Propose at least one program from the pre-approved list that can be delivered in a remote format, i.e., by video conference, phone, mailed toolkit + phone, or some other format that does not have an in-person component. The National Council on Aging (NCOA) maintains a website that tracks remote program guidance by program (https://www.ncoa.org/news/ncoa-news/center-for-healthy-aging-news/track-health-promotion-program-guidance-during-covid-19/). All applicants should contact the program administrator(s) for any program(s) they are interested in delivering remotely to confirm that: 1) the programs are allowed for remote delivery; and 2) that training is readily available for applicants who need it. It is incumbent on the applicant to provide evidence that any proposed remote program(s) are available in this modality, i.e., email or letter from program administrator, link to program website, etc. Note that the NCOA website includes programs on the pre-approved list in Appendix B and C, as well as other programs not on the list. For this funding opportunity, applicants may ONLY propose programs on the pre-approved lists in Appendix B and C.

State the projected total number of participants that you expect to reach through your proposed CDSME/self-management support programs. For any group series program, provide a target number of completers and a specific target completion rate. Provide a rationale for these targets, e.g., by referencing your previous experience delivering CDSME/self-management support programs, the number of older adults and adults with disabilities in your state/region/tribe with chronic conditions, saturation of target participant population (i.e. “low hanging fruit”), partner commitments, referral systems, and other factors. Targets should be realistic and achievable. In developing your participant/completer targets, please reference the Guidance for Administration for Community Living 2020 Chronic Disease Self-Management Education Grant Applicants:

Considerations for Estimating Participation and Completer Targets in Appendix E.

Describe how your approach will engage approximately 25% of your completer target (CDSME programs) and/or participant target (self-management support programs) by the end of Year 1, 50% by the end of Year 2, and 100% of your target by the end of Year 3.

Provide a coherent approach to implementing/disseminating the proposed CDSME/self-management support programs through your community integrated health network - with https://www.ncoa.org/news/ncoa-news/center-for-healthy-aging-news/track-health-promotion-program-guidance-during-covid-19/ https://www.ncoa.org/news/ncoa-news/center-for-healthy-aging-news/track-health-promotion-program-guidance-during-covid-19/ the overall goal of empowering older adults and adults with disabilities to better manage their chronic conditions.

Describe any existing CDSME, self-management support, and other evidence-based prevention initiatives in your area and how you plan to coordinate with and leverage these efforts. This should include a description of any existing capacity to deliver the proposed program(s), i.e., the number of host sites, implementation sites, and delivery personnel (such as trainers and leaders/coaches).

If your existing infrastructure for the proposed program(s) is inadequate, please describe and provide a rationale for any proposed training(s). If you require training, you must include a letter of support from the program developer(s) and/or entity that will provide training with your application. The letter should state that the training will be provided no more than three months after the applicant receives the Notice of Award from ACL.

For any remote program(s) proposed, please identify the IT/technological support needs you anticipate and provide a detailed plan for how you will address these.

Describe how you intend to identify, market to, and recruit participants for your proposed programs.

Describe any major challenges and barriers you anticipate encountering, and how your project will address those challenges and barriers.

Special Target Populations and Organizations

This section should:

Describe the target population that will be served by the proposed CDSME/self-management support programs. Also describe whether and, if so, how the proposed interventions will target any special groups and/or populations, i.e, underserved, rural, etc.

Provide a rationale (citing relevant data) for selecting the target group(s) and describe any involvement of organizations that would be collaborating in reaching the proposed population(s).

Work Plan

You should also provide a project Work Plan for Years 1, 2, and 3 which reflects and is consistent with the Project Narrative and Budgets. This Work Plan should include a statement of the project’s overall goals, anticipated outcomes, key objectives, and the major tasks/action steps that will be pursued to achieve the results-based goals and outcomes. It should also include tasks/action steps taken to evaluate progress toward goals and outcomes and effectiveness of relevant strategies. Applicants should identify timeframes involved (including start- and end-dates) and the lead person responsible for completing the task.

The Work Plan can be attached to your application as an appendix.

Outcomes and Evaluation Outcomes This section must clearly identify the outcomes that will result from your comprehensive strategy to implement this project.

Any proposed outcomes should:

address the goals of this funding opportunity (i.e., strengthening your community integrated health network and the delivery of CDSME/self-management support programs, with the goal of empowering older adults and adults with disabilities to better manage their chronic conditions); and be quantifiable, measurable, and likely to be achieved during the project period.

List measurable outcomes in the work plan grid under “Measurable Outcomes,” in addition to any discussion included in the narrative.

Quality Assurance This section should include the methods, techniques, and tools (including rapid cycle evaluation, Plan-Do-Study-Act, fidelity monitoring, etc.) that will be used to:

1. Monitor and track progress on the project’s objectives and activities;

2. Monitor whether the proposed CDSME/self-management support programs are being implemented with fidelity* and processes for corrective actions if necessary;

3. Ensure the ACL-required CDSME dataset (Appendix D) is being collected and reported accurately by the implementation sites and how you will identify and troubleshoot any potential problems.

4. Document the lessons learned, both positive and negative.

*Fidelity is the extent to which delivery of the evidence-based program consistently adheres to the program’s intent and design. In other words, the extent to which you are delivering the program exactly how it is meant to be implemented. Maintaining fidelity to the program is essential to ensure that your participants receive the intended health benefits from the program.

Dissemination This section should describe the method that will be used to disseminate the project’s results and findings in a timely manner and in easily understandable formats, to parties who might be interested in using the results to inform practice, service delivery, program development, and/or policy-making, including and especially those parties who would be interested in replicating the project.

Applicants should also clearly state their commitment to cooperating with any broader efforts led by ACL and/or the National CDSME Resource Center to help others understand how they could replicate the project activities in their communities.

In addition, all applicants should state their commitment to participating in to any national evaluations of the program(s) they have proposed for remote delivery.

Sustainability Sustainability In this section:

Describe your plans for expanding funding for your community integrated health network to ensure delivery of services and supports addressing the social and behavioral determinants of health, including the proposed CDSME/self-management support programs, beyond the end of the grant period. Applicants should detail:

o who your vested, experienced sustainability partners are and what their specific commitments to the project are;

o your proposed plans for contracts, partnerships, and/or collaborations with health care entities, insurance entities, large employers, the business community, or other innovative funding sources;

o any other business planning efforts to be undertaken;

o any mechanisms that are in development or already in place to accept payment for programs and services (i.e., infrastructure, Health IT, and back-office support to bill and accept reimbursement from contracts, private pay clients, and/or other potential payers);

and o your proposed or current centralized and coordinated processes to promote a unified and consistent approach across your state/region/tribe to achieve the goal of a and truly sustainable community integrated health network that offers a robust set of CDSME/self-management support programs. These processes may be operationalized by using a Network Hub approach (a Network Hub is akin to a Network Lead Entity, described in the Background section of the Funding Opportunity Description). For more information on this approach, visit https://www.ncoa.org/toolkits/community-integ rated-healthcare-toolkit/ and click on the Program Delivery and Evaluation section to view a description of Centralized and Coordinated Processes.

IMPORTANT: Your sustainability plan must include centralized efforts, through the community integrated health network, to expand funding for CDSME/self-management support programs using a mulit-payor approach. Sustainability plans should include, but not be limited to, health care funders. Applicants should not propose sustainability plans that rely solely on embedding CDSME/self-management support programs into existing community-based organization partner budgets or put the impetus on individual network partner agencies to seek/obtain funding on their own.

At the time of application, at least two of the network partners should provide firm commitments (in their letters of commitment) to helping secure and/or provide funding to sustain the evidence-based CDSME/self-management support program(s) beyond the end of the grant period.

Letters of Commitment

Provide letters of support confirming commitments from grant partners. These letters should describe the specific role of each partner in the project (should it be funded).

https://www.ncoa.org/toolkits/community-integrated-healthcare-toolkit/ https://www.ncoa.org/toolkits/community-integrated-healthcare-toolkit/ https://www.ncoa.org/toolkits/community-integrated-healthcare-toolkit/

Applicants must include the letters of commitment as an appendix to your application and use a Table of Contents to clearly describe which letters represent which partners:

1. All Community Integrated Health Network Partners. It is expected that all current/proposed network partners identified in the application provide letters of support, and identify their defined role in the project.

2. State Unit on Aging. It is expected that the State Unit on Aging will provide a letter affirming their support of your proposed project. If you are proposing a mulit-state network, you should have a letter from the State Unit on Aging in each state involved in the network.

If the State Unit(s) on Aging decline to provide a letter, you must provide documentation indicating this, e.g., an email from the State Unit on Aging stating that letters of support are not being provided. If you are a State Unit on Aging applicant, include a letter from your Director. This requirement is applicable for all applicants except tribes/tribal entities. You can locate this information applicable SUA information using the search feature on https://eldercare.acl.gov/Public/Index.aspx.

If you are a tribe or tribal entity, you must include a tribal resolution that states the reasons you are applying for the grant, and your commitment to executing the grant activities (should it be awarded).

3. Area Agency(ies) on Aging (AAA). It is expected that relevant AAAs will provide letters affirming their support of your proposed project (a letter from the state AAA association is not permissible in lieu of this requirement). This letter should reference their defined role in the project. Include a letter from the AAA(s) that reaches/covers your target geographic areas. If you are an applicant from a Single State Authority (Alaska, Delaware, Nevada, New Hampshire, North Dakota, Rhode Island, South Dakota, Washington DC, and Wyoming) or tribe/tribal entity, this requirement is not applicable. You can locate applicable AAA information using the search feature on https://eldercare.acl.gov/Public/Index.aspx.

4. Program Administrator. Applicants are expected to begin delivering their proposed CDSME/self-management support programs within three to six months after receiving their Notice of Award.